Inclusion and exclusion criteria

Studies were included if they:

• Used qualitative methods in their approach to data collection and analysis
• Included adults over 18 years of age experiencing socioeconomic deprivation (with a proxy or quantifiable measure) with two or more long-term conditions (MLTCs)
• Explored the self-management of MLTCs

Studies were excluded if:

• Data could not be separated to identify the perspectives of those experiencing socioeconomic deprivation
• We were unable to obtain full text in English
• The papers were review articles, editorials, or conference proceedings
• Studies did not focus on self-management of MLTCs

Search strategy

Database searches were conducted in MEDLINE, EMBASE, AMED, PsycINFO and CINAHL Plus. Databases were searched for key terms and Medical Subject Headings (MeSH) of self-management and variations of the terms ‘long-term conditions’ and ‘socioeconomic deprivation (e.g., socioeconomic status/position) were included, without date or language restrictions. Please see S1 Table for example search strategy. All article titles and abstracts were screened by two reviewers (AW and MA) independently and excluded if they did not meet the inclusion criteria. Full text papers were then screened by the first reviewer (AW) and all were checked by a second reviewer (MA). The eligibility of papers was discussed by the wider review team (CCG, ND, DN, JP, FS, KW).

Quality assessment

A quality assessment of the literature was carried out using the Critical Appraisal Skills Programme (CASP) tool [19]. This checklist consists of ten questions which look at the results of the studies, their validity (i.e., suitability of methodological approaches used to obtain them), and how valuable and/or transferral the results are. Studies were reviewed based on the results of the quality assessment, but no studies were excluded based on quality. Utilising the CASP method highlighted the range in quality of the studies and whether recruitment and data analysis techniques were appropriate. These factors have been taken into consideration during the presentation of results.

Thematic synthesis

The articles were analysed thematically to identify the main themes across all studies. Thematic synthesis involves three stages: the coding of text line-by-line; the development of descriptive themes; and the generation of analytical themes [16]. The results sections of each article were imported into NVivo 12 software by the first author (AW) who coded each line of text to develop a high-level coding framework around the self-management (as defined previously) of MLTCs and the barriers and facilitators to self-management among people experiencing socioeconomic deprivation. The coding framework was discussed by the wider review team (MA, CCG, ND, DN, JP, FS, KW) and then refined further as AW identified similarities and differences across the 11 studies to create descriptive themes. The descriptive themes were organised into ‘parent’ and ‘child’ nodes within NVivo to generate analytical themes based on the research question.

Study characteristics

All participants from across the 11 studies had characteristics associated with socioeconomic deprivation including low income, unemployment, low educational attainment, living in an area of high deprivation. One of the studies [21] also included data from participants living in areas low social deprivation which falls out of scope for this particular review. None of the studies utilised specific measurements of socioeconomic deprivation. The studies were conducted in Australia (n = 1), Canada (n = 1), South Africa (n = 2), the United Kingdom (n = 2), and the United States (n = 5). Many of the studies reviewed did not offer a clear definition of self-management.

All of the studies used one-to-one interviews as the data collection method with one study [20] conducting two interviews with each participant. Five of the studies [20, 21, 24, 28, 29] conducted interviews in participants’ own homes, five were conducted in a room at a community, healthcare/clinic setting [23, 25–27, 30] and one study did not specify a location [22]. The participant characteristics from the studies reviewed are presented in Table 1.

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Table 1. Primary study characteristics (n-11).

https://doi.org/10.1371/journal.pone.0282036.t001

Quality assessment

The CASP tool highlighted that some studies lacked detail about the methods used [22, 28] and several failed to explain the relationship between researchers and participants [20–22, 28–30]. The latter is of great importance within qualitative research to address issues of subjectivity and power imbalance [31]. The quality assessment also highlighted some issues due to vague or missing information, resulting in a ‘can’t tell’ score. For example, in relation to data collection procedures, one paper [22] references that the information is contained in an earlier publication but did not elaborate. There were also two papers that did not provide sufficient details relating to ethical considerations, beyond stating the study had been approved [20, 24]. See S2 Table for full quality assessment of the studies.

Data synthesis results

The data presented in this section were generated from a set of analytical themes as highlighted in Table 2.

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Table 2. Relationship between analytical themes and sub-themes.

https://doi.org/10.1371/journal.pone.0282036.t002

Prioritisation of conditions

Two studies [23, 29] describe how participants prioritised the management of certain conditions over others. In an Australian-based study [23], two participants were said to rate depression as their most important condition while another prioritised obesity because of its impact on their mental health. Symptoms of depression and mental health problems were recognised as a catalyst for worsening other health conditions and impacted broadly on self-management practices:

…it’d be so much easier if I just had one health problem I could work on and not have multiple problems… I got really bad a few months ago… I just stopped taking everything… I went into a really deep depression and couldn’t be bothered doing a thing. (p.9) [23]

Another study which was based in the US [29], reported that that juggling several conditions was more time consuming for people than management of a single condition. Participants typically prioritised conditions based on those that were most worrisome such as conditions that threatened functional decline. Due to having MLTCs, people struggled to find the time for self-care, but they also experienced difficulties affording medication and medical equipment; especially those not covered by Medicare (a federal health insurance programme for people aged 65 or older). One participant with six long-term conditions discussed the financial implications:

I need a new hearing aid, but we’ve just gotten him [husband] two new ones, so you can’t do it all. Medicare does not pay for glasses for older people or hearing aids…I don’t think that’s right, but they don’t [pay for them]. (p.9) [29]

Impact of multiple long-term conditions on mental health and wellbeing

The mental and psychological consequences of MLTCs among people experiencing socioeconomic deprivation featured in seven studies. One participant reported being unable to work because of her ill-health and described how her deterioration and inability to engage in everyday activities impacted on her mental wellbeing:

Sometimes I sit and cry. I do. I sit and cry ‘cause I think ‘God’s sake you’re only 50 years of age. How did it come to this that you’re in so much pain? That you’ve got all these things you’ve got to do? And you’ve got all these illnesses. Just one after the other’, you know, ‘everything seems to be happening’. I can’t make sense of it. (p.6) [28]

The co-existence between physical and mental health, and the impact upon self-management was discussed in seven studies [21, 23, 25–28, 30]:

…as you get older like I want to be fitter in myself and then… these little conditions, they stop you doing things, and then your motivation, if you’re feeling down and you’re depressed, then your motivation’s not there. (p.7) [21]

I get depressed because things don’t seem to happen quickly enough for me and I get upset that I can’t do things so I don’t eat, I stop taking my meds, I self-harm… things like that (p.8) [23]

Polypharmacy

In relation to the numerous medications needed to manage MLTCs, polypharmacy was reported as a concern in two of the studies [23, 29]. The specific challenges associated for people experiencing socioeconomic deprivation related to the costs incurred from having to take multiple medications:

When I’m charged through [Medicaid managed care plan], they charge one dollar for each prescription, and I take like 20–25 medications… that’s $30 per month, and I cannot afford that, and because of that, I’m having to pick and choose which medication to take and which medication to leave because I can’t afford to buy them, and it’s causing a lot of health problems… (p.54) [22]

While the above example was not an issue for all participants, those included in the US and Australian based studies described the issues surrounding medical costs. For one participant who experienced several changes to his medication because of the side-effects experienced, the financial outlay of multiple visits to his doctor was a challenge:

I paid $71 for a bottle of medicine. She [doctor] said I’m sorry but I’ve got to change this medicine. Said it’s too much for you. If the fluid gets too much for you then it makes you heart jump real fast. You have to get up in the night and everything cause it’s pounded too bad. Then I go back to the doctor and she said stop taking that. I want you to take this. (p.8) [29]

Maintaining independence

All studies discussed the capacity that individuals had for self-managing their conditions. Eight of the studies referred to the personal responsibility or self-reliance that participants felt towards maintaining their own health. For example, some were cautious of relinquishing tasks or chores to other people before necessary, to maintain some level of control over daily life:

Well I don’t get a lot of help from anybody cause I live by myself and I take care of my apartment and I do my groceries and things and some things the kids will do but not too much. ‘Cause the way I feel about it, the longer either physically and mentally, the longer I push to do these things, the longer I will be able to do them as I age in life. That’s the reason I like doing things for myself. (p.9) [29]

Similarly, some participants resisted asking for help in order to maintain some control or a sense of personal identity and pride:

I like to be strong and I’ve also took care of myself. I’ve never asked naebody [nobody] for help. Ever. I help everybody else. But I never ask for help… Now I just don’t want to ask for help. I just go without. I would just stay in. (p.7) [28]

Self-reliance could also be an impetus for gaining more knowledge about self-management:

We got to understand that we got to manage our own health because we care more about our health than others… As a patient you are responsible for your own self. (p.6) [20]

‘Meaningful’ activities

Working part-time was a favourable option among two participants of an Australian-based study [23], despite it being physically demanding and exacerbating their chronic pain. The study found that while employment provided greater financial security to participants compared to those in receipt of unemployment benefits from the state, employment was also beneficial to people’s mental wellbeing:

…with depression people handle it in different ways I keep busy I work I do things if I can’t work what happens I go downhill…as soon as I stop doing things I go downhill. (p.9) [23]

Correspondingly, as alluded to earlier, giving up employment or being of an age where one no longer worked, could result in experiences of social isolation and other mental health issues [28] that were counterproductive against self-management. It was important therefore in the absence of work to engage in other meaningful activities such as gardening or housework since these were linked to positive self-management practices:

I’ve got to be doing something. I’ve got to be tidying up. I’ve got to make sure my house is the way I want. No I wouldn’t sit in my own filth, no. I’ve got to do my housework whether it kills me or not. (p.6) [28]

Support networks

The theme of social (or informal) support appeared in nine of the studies [20–23, 25–27, 29, 30] but was demonstrated to varying degrees as some participants preferred to only lean on family or other support networks when necessary. The most typical examples focused upon physical activity such as exercise [21, 23–25, 27, 29, 30] and engaging with support groups and/or peer support, including faith groups [21, 25–29].

Peer support as a form of self-management intervention was shown to be vital for people experiencing homelessness, helping them to manage the emotional challenges of both MLTCs and homelessness:

…it’s good to have people to talk to…even if you knew people were just around… it just made you feel, sort of, better. (p.1428) [26]

Some people were able to implement and sustain lifestyle changes through other types of activity which in turn, helped them engage with a group of people with important commonalities:

I am part of an exercise group. I started last year and now I go every Thursday. I am really happy about joining. We are about 15 and everyone has a chronic illness, so we share ideas. (p.6) [27]

As demonstrated above, being around people who were in a relatable situation or just having someone to talk to, could provide mental health benefits [25]. While physical activity could be a way to connect to others with MLTCs some found exercise difficult or challenging to undertake; especially when experiencing chronic pain [23, 29]. This review shows however, that access to support provision varies across localities and could be offered as a free referral from a healthcare professional or incur a cost. Referrals to provision such as an exercise programme was a barrier to self-management for one participant who was struggling financially:

My doctor tells me it would be good for my sugar [diabetes] to take some exercise, but it’s hard—the rent, food, my medicine, it adds up. Joining a club’s not going to work. (p.9) [29]

Self-management was also facilitated at times by access to distributed health literacy since some participants had access to family members that helped provide emotional reassurances as well as typically providing tangible assistance:

She [my daughter] knows a lot and what to do in medical situations. So she was always there every day and every evening. And I have another daughter who is an accountant, so she did a good job of keeping up with all of my paying the bills because my husband doesn’t know a lot about writing a check or keeping up with the bills. So I do have great support from family. (p.9) [20]

Some participants concerned about their financial circumstances and how they could support their self-management, were able to ask family members for financial support. Examples of financial support included getting money from family to top-up low-income/benefits [23] and family members paying for prescriptions and buying specialist food items [29] such as getting help with buying healthy food as described below:

Mom and Dad help me, and that’s definite, they’ll help me; if I can’t buy the food, they’ll buy it for me. They’ve already said, We’d help you if you don’t make it, you know, but try and make it, because we’re not going to be around all the time…and they’re 78 and 77 years old right now… (p.55) [22]